Current face lifting procedure: an attempt at evaluation

A Systematic Review and Meta-Analysis of Early Relapse After Facelift

BACKGROUND

Early relapse is an adverse outcome of facelift surgery. The rate of early relapse is an indirect measure of the longevity and efficacy of facelift techniques. However, early relapse after facelift is ill-defined, under-evaluated, and under-reported, and literature data on the subject are dispersed. In this systematic review, we aimed to analyze facelift studies using relapse-related outcomes (RROs). Our secondary aim was to highlight the importance of early relapse as an essential outcome measure.

METHODS

The study design was a systematic review of the English literature and meta-analysis of RROs after facelift surgery. RROs that occurred within the first 2 years after surgery were considered "early". Performance, analysis, and reporting were performed in accordance with the PRISMA guidelines. The systematic search was conducted using the PubMed database as of February 2020. Initial screening was performed using the keywords "facelift", "rhytidectomy", "surgical rejuvenation", "face lift", "rhytidoplasty", and "facial rejuvenation". Articles were excluded by using a set of inclusion and exclusion criteria.

RESULTS

RROs were reported only in 4.4% (19/433) of the papers that underwent full-text review. The frequency of RROs ranged between 0.2 and 50% among facelift papers. The weighted median rate of RROs after facelift surgery was found to be 2.4% in the meta-analysis.

CONCLUSIONS

Future research on preventive measures will be successful upon acknowledgment of the actual prevalence of this problem. Consensus on its definition and objective criteria for its diagnosis are required for further progress.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques

BACKGROUND

Sub-superficial musculo-aponeurotic system (SMAS) rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, compared with less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection.

OBJECTIVES

The authors sought to aggregate and summarize data on complications among different SMAS facelift techniques.

METHODS

A broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total 183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rates of temporary nerve injury and were the only techniques to show a statistically significant difference compared with SMAS plication (odds ratio [OR] = 2.71 and 2.22, respectively, P < 0.05). Risk of permanent injury did not differ among techniques. An increase in major hematoma was found for the deep plane (1.22%, OR = 1.67, P < 0.05) and SMAS imbrication (1.92%, OR = 2.65, P < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR = 2.29, P < 0.01).

CONCLUSIONS

There are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Technique should be selected based on quality of results and not the complication profile.

LEVEL OF EVIDENCE: 2

The surgical anatomy of the parotid fascia

Currently, there are no reports in the literature of the parotid fascia suggesting that this structure is crucial to the identification of the facial nerve trunk (FNT). Traditional surgical and anatomical descriptions of this fascia report it as a collection of connective tissue large enough to be described by the unaided eye. This study was performed to investigate the composition and limit of the fascia surrounding the parotid gland. An appreciation of these on safe and effective parotid surgery was also considered. HISTO-ANATOMICAL STUDY: Microsurgical step-by-step dissection was performed on 18 adult cadavers (n=36) to define the composition, arrangement, and attachment of the parotid fascia. Samples were subjected to the Masson Trichrome Technique (1990).

CLINICAL STUDY

A total of 18 patients presented for parotidectomy. Eight patients had a pleomorphic adenoma and ten had lympho-epithelial disease of the parotid gland. Boundaries of parotid fascia were posteriorly-mastoid process, anteriorly--ramus of mandible, superiorly--cartilage of external acoustic meatus, and inferiorly-imaginary line joining tip of mastoid process to ramus of mandible. These landmarks formed a quadrangular space. HISTO-ANATOMICAL STUDY (N=36): Parotid fascia formed a fibrous meshwork over the gland. In the upper two-thirds, fascia was thick and strong; in the lower one-third, fascia was thin. Soft tissue arrangement (from superficial to deep): dermis, subcutaneous fat, superficial cervical fascia, deep cervical fascia. CLINICAL STUDY (N=18): The technique described was applied consistently in all patients. Mean time for localization of FNT was 11 min (range 7-18 min). In two patients (both with an underlying inflammatory disorder of the parotid gland), a transient facial nerve palsy developed postoperatively. In both patients, this settled within 7 weeks of operation. The true surgical potential of the parotid fascia during parotidectomy has been reported.

The changing role of platysma in face lifting

Since the 1970s, surgical procedures on platysma muscle, aiming to achieve better results in face lifting, became popular and turned out to be an important surgical step for the plastic surgeon. Many plastic surgeons have contributed to the topic throughout these years, as several articles on the subject have been published. Articles dealing with platysma muscle still bring great interest among plastic surgeons. My concern with platysma muscle began in the mid-1970s and since then has grown continuously. I have steadily been studying the importance of the platysma muscle in the surgeries for facial rejuvenation, involving its anatomy, the techniques proposed, the results obtained, the recommendations for the best surgical procedure for each patient, and the complications. My experience and studies regarding platysma muscle, and the contributions I have brought into this field, are thoroughly described and discussed in this article.

The medial SMAS lift with aggressive temporal skin takeout

The ability to correct prominent nasolabial folds has remained a consistent weakness in facial rejuvenation surgery. Cadaveric studies were performed to evaluate differential properties of the superficial musculoaponeurotic system (SMAS) unit. We have found that the medial portion of the SMAS unit has a much more scattered, irregular collagen architecture and exhibits greater distensibility. Based on the regional differences in the physical properties and architecture of the SMAS, a face lift procedure is described in which the medial portion of the SMAS is resuspended, combined with aggressive temporal skin takeout in a pants-over-vest fashion. The procedure has been performed by the senior author in 89 patients. It is often combined with the "central" suspension and has provided more predictable results in this surgeon's hands.

Mechanical properties and microstructure of the superficial musculoaponeurotic system

Because of the widespread reliance on SMAS tightening procedures in present-day face lift surgery, a study was undertaken to examine the physical properties and microscopic structure of both virginal (40 specimens) and reoperated (8 specimens) SMAS tissue. The findings could be of practical value to the surgeon and are reported herewith: First, the SMAS is a composite fibrofatty layer comprising collagen and elastic fibers interspersed with fat cells. Second, microscopic appearance shows a considerable amount of elastic fibers in close relationship to the collagen fibers. Third, on scanning electron microscopy, the collagen fibers in the virginal SMAS show a convoluted appearance similar to that found in the dermis. In the reexcised SMAS tissue, there is some evidence of parallelization of the collagen fibers as seen in the stretched dermis. Fourth, mechanical testing (Instron), i.e., a series of loading/unloading tests at various rates and amplitudes, and stress relaxation tests were performed on samples of preauricular skin and SMAS. These indicated definite viscoelastic properties for both sets of specimens, with the tendency of an increased stiffness and a reduction in viscoelastic effects on repeated working of the samples. Overall, the mechanical behavior of both tissues was somewhat similar, the viscoelastic effects in SMAS being less pronounced. A nonlinear viscoelastic model is under development to represent the behavior of both tissues. The implications of these results may help to explain the slackening effect observed in some postoperative patients.